Inspection on 25/11/08 for Perry Locks Nursing Home

This inspection was carried out on 25th November 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Perry Locks Nursing Home 26/02/10

Perry Locks Nursing Home 20/05/09

Perry Locks Nursing Home 04/02/08

Perry Locks Nursing Home 26/09/06

Perry Locks Nursing Home 02/02/06

Perry Locks Nursing Home 26/09/05

Perry Locks Nursing Home 07/12/04

Perry Locks Nursing Home 15/07/04

Perry Locks Nursing Home 21/01/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2009.

CARE HOMES FOR OLDER PEOPLE Perry Locks Nursing Home 398 Aldridge Road Perry Barr Birmingham West Midlands B44 8BG Lead Inspector Karen Thompson Key Unannounced Inspection 25th November 2008 07:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Perry Locks Nursing Home Address 398 Aldridge Road Perry Barr Birmingham West Midlands B44 8BG 0121 356 0598 0121 331 1261 slyms@bupa.com www.bupa.com BUPA Care Homes (CFHCare) Ltd Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Manager post vacant Care Home 120 Category(ies) of Dementia (120), Mental disorder, excluding registration, with number learning disability or dementia (120), Old age, of places not falling within any other category (120), Physical disability (120) Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing (code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 120 Old age not falling within any other category (OP) 120 Physical Disability (PD) 120 Mental Disorder (MD) 120 The maximum number of service users to be accommodated is 120. 4th February 2008 (Key Inspection) Random Inspections: 11th & 12th September 2008 2nd October 2008 6th October 2008 2. Date of last inspection Brief Description of the Service: Perry Locks is a modern purpose built Nursing Home and is part of the BUPA organisation. The home comprises of four separate units, each with thirty beds. The home is registered to care for people with a number of health care needs including: dementia, physical disability, mental health problems and conditions relating to older age. All units have access to a garden area plus a lounge/dining room and a quiet room available for people who live in the home. There is off road parking facilities at the front of the home. All bedrooms are single occupancy with a wash hand basin. The home is situated beside a canal in a residential area, four miles from Birmingham City Centre. The home has a perimeter fence that enables security and safety of residents. It is sited close to a local bus route and local shops are a reasonable distance away. Currently the home is in a process of completing building work on a new extension to increase the number of beds. Whilst this work is being done discreetly as possibly the work is having an impact on the overall grounds of the home with metal fences one of which screens the garden to Perrywell Unit. There is also a loss of available car parking facilities due to building materials, plant hire vehicles and storage facilities. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 5 Fees vary and are dependent on the needs of people who require the service. Items not covered by the fees include toiletries, visitor’s meals, continence products, private treatments such as physiotherapy and chiropody, escort by a member of staff outside the home, hairdressings and newspapers. The current scales of charges for the home range from £491 to £1299 per week. The home retains the nursing element of the fee, which is paid by the Primary Care Trust. For up to date fee information the public are advised to contact the home. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that people who use this service experience Poor quality outcomes. This was an unannounced inspection; the home did not know we were coming. It was carried out by three inspectors who were there for a two-day period and a Pharmacy Inspector carried out an inspection on the 11th & 26th November 2008 in order to check the homes compliance with a Statutory Requirement Notice and those findings are contained within this report. A Regulation Manager also attended on the 25th November 2008. The focus of inspection undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirement, minimum standards of practice and focuses on aspects of service provision that need further development. Following the inspection all of the findings were collated and we met with BUPA’s managers on the 1st December 2008 to provide headline feedback. Representatives from the BUPA management team were available for the duration of the inspection and provided any necessary documentation. Information for the report was gathered from a number of sources including: a questionnaire AQAA (Annual Quality Audit Assessment) which is completed by the Manager in July 08 which details information about improvements and what they may need to improve upon. Records and documents were examined in relation to the management of the home plus conversations with managerial staff and a number of care staff and people living across the whole home. There were no visiting relatives available to speak to at the time of the inspection. However, we had communication from a number of relatives by telephone, email and surveys both prior to and after the inspection visit concluded. The inspection process also took account of information received from the home in the form of Notifications about events that had affected people’s wellbeing living in the home. We also took account of information shared with us by Birmingham Adults and Communities Directorate as part of the on-going matters relating to safeguarding of people living in the home. A Short Observational Framework inspection (SOFI) was commenced; this is a tool we use to observe people who are unable to communicate their views verbally to the inspector. We had to stop the observation due to one person at the home being distressed by the inspector sitting in the lounge. All four units were visited during the inspection however the inspection concentrated mainly on the care provided to people who live on the Perry Well, Brooklyn and Lawrence units. Ten people were case tracked this involves Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 7 establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. To help us identify and case track people and their needs the Manager was asked to complete a needs profile of all persons living in the home. This information would help us identify the range of peoples needs and who they were. Tracking peoples care helps us understand the experience of people who use the service. Eighty questionnaires were forwarded to a randomly selected number of people living at the home, relatives and health professionals prior to the inspection of which twenty eight were returned. Comments from the returned questionnaires and those people living at the home have been incorporated into the report along with comments from staff working at the home. We have also used the information received from relatives who contacted us directly. Since the last key inspection visit we received information about urgent matters that were affecting people living in the home. It was decided that these matters had to be followed up in the form of a Random Inspection. An initial Random Inspection was carried out on the 11th & 12th September 2008. A number of serious concerns about peoples care were identified and these included: poor medication administration that identified the over use sedative medication, poor care planning including identifying risks and overall care delivery. Following the random inspection visit of 11th and 12th September 2008 the Regional Director for BUPA was asked to attend a meeting with CSCI so that we could share our serious concerns about the service. At this meeting the home agreed to some conditions that should improve the quality of care provided in the home. We also met to share information about our serious concerns about the service provided with Adults and Communities Directorate (Social Service), Police, Primary Care Trust (PCT), and Commissioners of care. After the September 2008 inspection visit we carried out further Random Inspection visits to follow up matters that gave cause for serious concern. The first was carried out on 2nd October 2008 and looked specifically at the standards of care provided to people in the Perrywell Unit. On the 6th October 2008 the Pharmacist Inspector carried out a random inspection and identified further breaches of regulations about medication management that was placing peoples health and well-being at risk. As a consequence the Commission issued a statutory Requirement Notice that required the home to make improvements to the standards of medication administration that included medication given to people and the medication records. As part of this Key inspection the Pharmacy Inspector carried out a further Inspection visit on the 11th & 26th November 2008 in order to look at medication administration on all four Units and check compliance with the Statutory Requirement Notice. The Pharmacy inspection gathered evidence that showed that the home had breached the Notice and the Commission is considering the next steps to take. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 8 Following this key inspection visit we issued Statutory Requirement Notice about Care Planning. Due to the serious concerns within the home, BUPA have responded by reviewing the operational management structure within the home and providing us with a revised improvement plan to improve standards. We will continue to monitor the home to determine the progress in meeting peoples needs and take appropriate action where necessary. What the service does well: What has improved since the last inspection? What they could do better: Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 9 The medicine management must improve to safeguard those people that live in the home. Whilst improvements were seen further improvements must be made to ensure that all the residents receive their medication as prescribed at all times. Activities must be available so that people living at the home lead a stimulating and fulfilling lifestyle that meets their tastes and interests. Arrangements must be in place so that any bedrails in use are fitted safely and are fully risk assessed to prevent possible injury. The home must improve its arrangements for safeguarding people in their care so that they can be confident their best interests are being respected and promoted. Strong Leadership is needed across all areas of the running of the home to ensure the home is run in a way that meets the needs and expectations of the people living there. The home needs to improve the way that it provides care to people who suffer with dementia so that their safety, dignity and well-being is respected and promoted. A review of the manual handling equipment should take place to ensure that staff have the means to safely move people at the home according to their individual assessment needs. Overall communication systems with everyone within the home must improve so that concerns can be dealt with appropriately. Managers must take responsibility for how matters are communicated so that staff are not left confused and disaffected. The arrangements for Care Plans need to improve in order that all new and emerging care needs are identified, assessed and addressed in the documentation. The home must then ensure that care plans are implemented as working documents to guide all staff so that the overall care delivery can be improved to make sure all of peoples needs are met. The quality and timing of meals provided and the dining experience for residents must be reviewed and action taken to ensure residents receive food and drinks that meets their nutritional needs. There must be greater awareness by staff of their role in promoting privacy and dignity for residents in the home so that their rights are promoted and protected. The staffing levels and deployment of staff needs to be reviewed across the home to ensure residents’ needs are met appropriately at all times by people who know them well. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 10 The Statement of Purpose must accurately reflect the overall care provided so that people are clear what is offered. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 11 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 12 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1.3.4. (At this time the home does not provide intermediate care as identified in standard 6) Quality in this outcome area is adequate Arrangement in place do not ensure that people can be confident that their needs will be met on admission to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since 11 September 2008 there have been no new admissions to the home as part of the agreement with BUPA. We looked at the assessment document of three people who had been admitted to the home prior to September. The assessments had been completed and care plans had been written in relation to the majority of peoples needs. What was not evident was how the service involved people in Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 13 the process. We spoke to one person who said staff had talked to them about their care, but they felt it had been decided before they moved into the home in conjunction with their relative. This does not ensure the peoples individual and personal needs are fully met on entering the home. One care plan was observed to have been completed by a trained member of staff who was seen on the staff rota as only working nights. This practice allows for very little input from the person who the care is being planned for and/or their representative. This person was spoken with during the inspection and was able to communicate their needs. This raises concerns about the assessment and care planning process and does not guarantee that all needs are met. Discussions with staff highlighted staff concerns over training and they felt ill prepared to care for people who were physically and verbally aggressive towards them. Dementia care training covers what challenging behaviour is but does not teach them breakaway techniques and staff were unsure of what to do in this circumstance. Staff we spoke to on Perrywell said that they had discussed this with the management, but were still unsure. A number of people living in the home have been admitted to hospital and are being reassessed by the PCT and the management of the home. This is to determine if peoples needs can be met before returning to the home to ensure their health and well being upon return. The home has 17 GPs some of them refuse to visit the home resulting on occasions people being admitted to hospital for health checks. Where appropriate these people have returned. It was decided and agreed that if the admission to hospital was due in part to the home failing to deliver appropriate and timely care persons would not return to the home in line with the voluntary undertaking. The Statement of Purpose was reviewed and parts re-written in June 2008. However, the Statement of Purpose is not fully accurate and needs amending to reflect there is currently no Registered Manager. The core values of the statement of purpose will be discussed further in the health and personal care section. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 14 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10.11 Quality in this outcome area is poor. The arrangements for meeting peoples health and personal care needs including medication are not always being adequately, consistently and appropriately met which puts them at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose for BUPA Care Homes has clear stated aims and objectives. It was evident during the inspection activity since September 2008 that the home is failing to deliver to thee core values. The competency tests have been introduced for nursing staff in an attempt to ensure they were able to take control of all aspects in the delivery of peoples Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 15 care. What is concerning, however, is that two members of staff who was deemed competent by the management team were observed to lack the knowledge and skills in relation to specific care needs. Managers shared the Competency Framework with us including the completed paperwork. This paperwork was examined and confirmed that staff were able to answer the questions. One nurse deemed as competent made a serious error in medication administration, which was observed during the inspection. This does raise doubts about the standard of competency testing that was carried out in that it failed to take into consideration actual operational practice of those nurses assessed. Relatives provided mixed feedback about health care needs being met and staff communication with them. Surveys from relatives stated for example important health concerns are always responded to. They will always reply to concerns but some minor things dont get resolved may there isnt a solution (continual itches, aches and pains cant get comfortable), Excellent for this my …prone to chest infection and not only are these dealt with promptly but I am always contacted if they are getting doctor in, medication not always given on time. However relatives who have contacted the us highlighted a number of areas where health needs were not being met. People living in the home also provided mixed feedback about a number of areas. One area of concern was in relation to the poor response to call bells. Comments included, We just have to wait and wait; feels nervous if hanging about One person living in the home had no system for summoning assistance and they stated. Have to wait hours for assistance after midnight … have to shout and shout and they don’t come. Another person stated, Staff are very busy during the day so I may have to wait. There are a lot busier than they were a year ago. On the second day of inspection the inspector visited one person in their room. On entering the room the call bell was alarming and continued for fifteen minutes. The inspector went to investigate this further and found three members of staff on the unit. The inspector was informed that two members of staff hold pagers to alert staff of calls and both had left the building for a break. The lack of a timely response to call bells has had an impact on the quality of care delivered to residents. The person who had being trying to get assistance was in need of personal care that if left could lead to skin problems. People living in the home have a care plan, which outlines their needs and the action required by staff to meet their needs. There was also a range of risk assessments that highlighted potential risks and the action required to minimise them. Each person case tracked had their own care plan. In some cases care plans and risk assessments had not been reviewed for some time. There needs to be regular reviews as some peoples needs change on a very regular basis e.g. one persons moving and handling risk assessment had not been reviewed since 17/08/08 and their assessment stated that the person Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 16 should be moved with a specific hoist and sling. It was observed that this person was being moved by two carers using an under arm support lift and could weight bear. This was discussed with two members of care staff who confirmed that a hoist had never been used to transfer of this person. A care plan identified a person had a visual impairment, yet the care manager and trained member of staff were unaware of this. This is concerning as it indicates staff in charge of promoting a persons well being are not aware of their needs and this impacts on care given. We looked at care plans for people and found that they were not always being reviewed in a timely manner and failed to take account of peoples changing and developing needs. A number of these were serious failures in that the lack of appropriate care meant people had become dehydrated. There have been a number of serious concerns regarding peoples nutritional and hydration needs. All peoples nutritional needs are assessed using the MUST tool. However, where concerns were identified care plans were confusing in some cases and others did not give the information required to meet people’s nutritional needs. Therefore it could not be guaranteed that peoples nutritional needs are being met appropriately. During the September 2008 both the Commission and the visiting Primary Care Trust highlighted concerns about people who were getting their nutritional needs met via medically assisted route. However, since that time there have been some improvements for people who were provided nutrition in this way due to the intervention of the local Primary Care Trust. Mealtimes were observed and found to be problematic and this impacts on the nutrition and hydration of people living in the home. This will be discussed fully in the next section of the report. The PCT tissue viability team undertook an assessment of all peoples skin integrity during October and November 2008. We have been informed by the tissue viability nursing service that feedback was given to the staff for each person assessed and the tissue viability nurses recorded clinical findings in each persons care plan. In addition a comprehensive written report was forwarded to the home following completion of the audit. A significant number of pressure relieving seating cushions were found to be unfit for purpose and were condemned. There were a number of foam mattresses on divan metal bed frames that over hung making the bed unsafe on some units. Some mattresses were condemned and the majority were replaced on the day from existing stock. Although this action was positive it was concerning that staff had not identified the problems with equipment and taken appropriate action until it was highlighted by external visiting professionals. The audit identified that people living on two of the units had not pressure ulcers and that on the other two units the incident rate was 8 and 18 of people. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 17 The tissue viability nurses identified that two air mattresses were alarming, which indicated a fault and compromises the effect of pressure relief, so putting the person at risk of pressure sores. On the first day of our inspection an air mattress was found to be alarming and this was pointed out to staff. On returning for the second day of inspection the same mattress was found to be alarming again. The member of staff failed to adjust the mattress equipment and switched the alarm off. The mattress was over inflating for the weight of the person using it. It was also identified during the tissue viability audit a person living at the home was found to have pressure ulcers, which were not acknowledged as a needs in the care plan. This means that people are at serious risk from harm. The tissue viability service highlighted that there was a lack of knowledge regarding people living in the home from the trained nurses working on the Brooklyn Unit. Training records indicated that staff had not received training in respect of tissue viability recently and there was no evidence provided indicating plans for this training. On one of the units the tissue viability nursing service identified a number of people with a rash. All the individuals were being treated by their individual GPs but staff at the home had not considered whether there could possibly have been a link. This was discussed with the unit manager during inspection who felt everyone had individual reasons for the rash. Cross contamination was discussed and this had not been explored by the home despite a previous outbreak of an infectious disease some months previously. The PCT have arranged for a specialist to review the rashes of these people to determine the cause. Bed safety rails were observed on a number of people beds. These are generally used to protect people who are at risk of harming themselves by falling out of bed. The use of Bedrails needs to be based on a through assessment. Care plan had restraint forms in place for the use of bedrails. The restraint form has a section to indicate who has been involved in the decision making process but on a number of these forms it was evident that only the trained nurse of the home had made the decision. The form guides staff to consider input from the multi-disciplinary team. A multi-disciplinary team decision ensures that people who live at the home have their rights balanced against risks. The tissue viability nurse service had identified that not all bed rails were fitted with suitably fitting bumpers; this therefore places the person at risk of harm. We observed that some of the fitted bumpers did not cover the entire rail and this could be a risk to the person in that bed. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 18 Staff handovers were observed on two units during the inspection. However on discussion with staff they stated handovers do not regularly occur. A number of people were observed being cared for in kirton/ bucket chairs. People living at the home were observed to be moved around the home in these chairs. These chairs place high pressure on the sacrum and buttocks and can also be used as a form of restraint. During the inspection visit it came to our attention that these chairs were being used in some instances as a form of restraint to prevent people moving freely around the home and this was confirmed on discussion with staff. An immediate requirement was left with the management team to review all people using this type of chair to determine if there was a therapeutic reason for its use. We have since been informed by BUPA that all thirty people have been reviewed and nine people are no longer using these chairs. This would indicate that approximately one third of people placed in these chairs inappropriately for protracted periods and therefore being restrained. There was no restraint form in use for these chairs. On examining the organisations own guidance and procedure on restraint it was evidently clear the home has failed to follow its own procedures. During this inspection and at the time of the previous random inspection a number of unexplained injuries had been recorded in peoples care plans and there was no evidence of any investigation by staff to determine the causes of the injuries. One persons file contained photographs of unexplained bruising, but again there was no investigation into the cause of them. Following the inspection the management team has notified us that a member of staff has been suspended following an incident of a new unexplained injury and this has been referred to Adults and Communities Directorate under the Safeguarding procedures. On visiting the Perrywell unit there were two hoists and only two slings available to support people safely. The majority of the people need assistance with manual handling and this may be a contributory factor in the number of unexplained injuries. Staff on this unit stated The hoist is rubbish, running out (of charge) and does not go very high. One member of staff was concerned someone may one day be suspended in the air because the hoist had broken down. As highlighted in the Summary the SOFI observation that was being conducted on the Perrywell unit had to be abandoned due to one person living at the home becoming extremely distressed by the presence of an inspector. Due to the lack of positive staff intervention this person was also seen to physically assault a visiting professional. There was no written guidance for staff to follow so that they had the information they needed to support this person. An immediate requirement was left with the management team in relation to Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 19 safely managing such behaviour. Following this visit we were informed that the home had sought advice on how to work best with this person. A copy of a letter to a GP signed by relatives was found in one persons file, which stated the person was not for resuscitation as agreed in hospital. In addition, they should not be sent to hospital in the event of any deterioration in their condition. A care plan was in place for end of life care, but it was not appropriate and it was obvious from it that their condition had improved. This raises questions as to the appropriateness of the order as peoples needs should be constantly reviewed and care changed accordingly. On discussion with a member of staff they were aware of the letter, but lacked understanding about the Do not resuscitate order. During the inspection in September 2008 concerns were also raised about end of life care planning. A requirement was made at that time that staff should receive training in end of life care by the end of October 2008 appropriate to their position to ensure peoples needs were met. There appears to have been no improvement in this process and there was no evidence from the training matrix of any training in end of life care and there was no evidence for such training in the near future. This requirement remains outstanding and we will be considering the next step to be taken. Since the inspection in February 2008 we have been informed that appropriate locks have been fitted to peoples bedroom doors to enhance privacy. The new locks were in the form of thumb turn devices on the inside and key access on the outside. Some staff were seen to interact with people very well and showed respect. However, one person was observed to have a full urinary catheter leg bag in position for some time. This was not secured appropriately and was on display to all beneath their clothing. Care needs to be taken by staff to ensure that the appropriate securing, positioning and emptying of catheter bags to ensure all peoples dignity is promoted. The pharmacist inspection took place on 11th November and 26th November 2008. All four units were inspected. Eighteen peoples medicines, charts and care plans were looked at. The nurse on duty at the time of the inspection on each unit was spoken with and all feedback was given to the manager and deputy manager. A statutory requirement notice was issued on 24th October 2008 due to sustained breaches in the regulation 13(2), found at the last pharmacist inspection on 6th October 2008. You were required by 10th November to: 1. Put in place arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 20 This had not been met at this inspection. Despite regular audits undertaken by the nursing staff and competency tests completed for some of the nurses, by the managerial staff mistakes were still evident. No action appeared to have been taken when the daily audits indicated that the medication had not been administered as the doctor prescribed. The value of the daily count of tablets is questionable if staff do not act when they find a discrepancy. Not all the nursing staff had been assessed for their competence in the safe handling of medicines despite BUPAs assurance that these would be completed before nursing staff handled medication. Poor practice by one nurse was seen despite being assessed as competent. Medicines had been recorded as administered when they had not been and medicines were unaccounted for. In one instance only one tablet had been administered even though the prescribed dose was three tablets. In another instance either a complete dose of two capsules had not been given or two doses had been administered at half the prescribed dose. Many other errors were seen. Despite a system installed by the home to check the prescription prior to dispensing to confirm that the medicines they required had been prescribed and received into the home, this did not take place. This resulted in at least three residents not having some of their prescribed medication for up to eight days while a supply was sought. Nursing staff had not adequately checked the prescriptions, or checked the medicines dispensed and received into the home in time to prevent this error. This is of serious concern. One person living at the home went without pain relieving medication for three days while a new supply was sought. Another went without a medicine to prevent blood clots for eight days. Nursing staff did not at any time try to obtain an emergency supply from the pharmacist to ensure that the residents received their medication as the doctor intended. Not all the medicines balances carried over from previous cycles had been recorded and this resulted in not being able to undertake audits to confirm that the medicines had been administered as prescribed. In two units the air conditioning unit had not been connected. This resulted in the ambient room temperature being too high (26°C) which may affect the stability of the medicines kept within. Despite assurances this would be connected within the next 24 hours this did not occur and the second air conditioning unit was not connected until the second pharmacist inspection two weeks later. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 21 The medicine refrigerator temperature range was too high. This meant that medicines stored within may have their stability compromised, which may affect whether they work or not. As seen at the last inspection the medicine round still finished late. This would have an impact on the next medicine round and concern was raised that there would be insufficient time between medicine rounds to ensure that potential drug overdose did not occur. At least four hours must elapse between medicine rounds. This is difficult to do when the morning round does not finish until almost 11:30am. In addition the resident may go without some medicines for over twelve hours from the evening to the morning medicine round. This may result in some residents not receiving adequate pain relief during the night, for example, if the maximum daily dose has been squeezed in over the twelve-hour period during the day. Despite new books purchased detailing the recommended way that medicines are administered via a PEG tube, staff had failed to consider that changing all tablet form medication to liquid form, whether recommended or not may have an impact on the sorbitol level the resident received. One person living at the home suffered from loose stools, which may have resulted in the increase in sorbitol (a known laxative). Care plans remained insufficient for nursing staff to adminsiter medicines via this route correctly. One medicine was not administered as too viscous. It tended to block the tube. The care plans did not record that this particular medicine should be diluted with three to four times its volume of water to aid administration. Again nursing staff are not using the medical information provided to maintain the health and well being of the residents. Some very poor practice was seen resulting in the nurse being suspended from duty pending further investigation. Two boxes of medicines were available for two people living at the home, one at a strength of 30mg and one 15mg. The incorrect strength of one tablet (30mg) was offered to the wrong resident. The resident refused this and it was discarded. We, the commission, pointed out this error. The nurse then took the discarded 30mg tablet out of the bin and said it could now be given to the correct resident. Following further questioning it was decided that a new supply could be sought from the doctor to make up this shortfall for the resident. The nurse could not have checked the medicine as the incorrect box was selected and had a total disregard for the potential contamination of the tablet taken from the bin to given to the correct resident. The nurse then went on to prepare medicines for the resident and took all the medicines from the blister packs out for the morning dose and put them into a pot. She then took the trolley together with the folder of medicine charts and pot of already prepared tablets to this person. We, the commission asked her if she would like the medicine chart for this person as it had been removed from the folder. The nurse had not checked the medicine chart before the preparation of the medication. This increases the risk of error Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 22 as the incorrect medication or not all the medication may be selected. This nurse had been assessed as competent to handle medication by BUPA. The majority of the nurses spoken with had a better knowledge of the medicines they handled, which was commended. However one nurse still did not know what the correct dose of one sedating medicine was. This had been prescribed at twice the recommended dose for the residents age. Without such knowledge nurses are unable to fully support the clinical needs of the residents they look after. Concern was raised that nursing staff are not applying their clinical knowledge correctly. One resident had been prescribed two laxatives for constipation. One was not given because the resident had loose stools but the second one was. This happened on a daily basis and at no time did the nurse discuss this with the doctor or just not give the laxatives at all. The care plans had improved and they gave a detailed reason why each medicine had been prescribed. Pain assessments had been completed but they lacked details. For example, how nursing staff know if a resident is in pain if they cannot communicate verbally. These pain assessments would be of little value for new or agency staff. It was bought to the commissions attention that one person living at the home had been prescribed and administered an antibiotic despite being allergic to them. The nursing staff had not recognised this. We, the commission asked to see the medicine chart but this was not available during the inspection and appeared to have been lost. Some good practice was seen. The PCT has reviewed many of the people living at the home and the overall level of sedating medicines prescribed had been reduced. Nursing staff on Perrywell regularly communicate with the doctors if people living at the home constantly refuse their prescribed medication. This had been documented clearly in the daily records. The controlled drug balances were correct and all had been stored correctly. However a wallet containing bankcards was found in one CD cabinet. This should be reserved for the storage of CDs only. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 23 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate People living in at the home would benefit from the opportunity to take part in a wider range of activities so that they are enabled to lead a more stimulating and fulfilling life. People are supported to maintain contact with family and friends so that they are able to maintain the relationships that are important to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has arrangements in place to provide a range of activities for people living in the home. A plan of activities was observed on a notice board in relation to the Christmas period and included a pantomime, a party and a visit by Elvis. Four activity co-ordinators are employed and each work on a designated unit. Inspectors spoke to one activities co-coordinator and they stated they had attended a one day course in respect of activities. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 24 The activities co-ordinator for Lawrence Unit was on holiday and a session was held by another co-ordinator, which consisted of a quiz. At the beginning of the quiz a person living at the home asked, are you doing the drinks and the response from the activities co-ordinator was You don’t want another one do you. This style of relating to people is closed and fails to enable people to explore all areas of their needs or ask for anything different. At one time the inspector observed two different songs being played in the same lounge at the same time and in another lounge two televisions on different channels competing with each other. Both of these would be confusing to people living in the home especially if they have any cognitive impairment. This was relayed to the Care Manager who said when the home is refurnished there will be a new large television installed. This missed the point of the issue raised, as the removal of one television would have made an immediate improvement. A record of activities undertaken by people is maintained in their individual care plan file. One person living at the home had 11 activities recorded from the end of August to 20th November 2008 of which 10 were assistance with feeding. Although interaction takes place when feeding it cannot be deemed as a social activity as in such a case it is a fundamental basic need for the person. The activities co-ordinator interviewed stated it was normal for them to assist with feeding. We overheard a member of staff say to people that the quiz would not be occurring a regular basis and was a treat for today. Care plans were in place, which contained vague general statements about social needs e.g. Needs to be involved in appropriate activities. However, it did not state what activities these could be. This does not demonstrate that activities are being tailored to meet individuals needs or preferences. On the second day of inspection people were taken to the main administration block to see the hairdresser. They were lined up in the corridor and no member of care staff was supervising them to ensure their safety. This seemed a very institutional approach to providing what should be a positive experience. There is open visiting policy enabling people to maintain contact with friends and relatives at a time that suits them and relatives confirmed this. Breakfast was observed to be taking place on the Brooklyn unit on the first day of inspection. The inspector was informed that some people remain in their bedrooms for breakfast and one person was having a lie in demonstrating people are given a choice about what time they get up and where they choose to eat their meal. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 25 One member of staff was allocated to the dining area on Brooklyn to help and assist people with their breakfast at observed at 8:57 am, the inspector was told that seven people had already had their breakfast. The member of staff in the dining room assisted discretely with good interaction between them and people having their breakfast. However, Breakfast did not finish until 11:45 am. for all people on the unit. This can potentially have an impact on peoples nutrition and hydration needs due to the long period between meals e.g. Supper and breakfast on the following day. This practice may add to peoples confusion and then to be offered a large meal one and hours and fifteen minutes later may mean some people refuse or only eat part of this meal. Staff were asked why breakfasts had taken so long. They stated the routine had recently changed and the night staff were no longer getting people who are cared for in bed washed and dressed in the morning. This is positive, but has impacted on the workload of the day staff and their ability to ensure all people receive their breakfast in a timely manner. This raises concerns about the adequacy of staffing at this time in the morning. Staffing levels will be discussed in more detail later in the report under the staffing section of the report. General comments in relation to food varied and included , Horrible, tastes the same all the time. They do the best they can. The food is quite good, but on occasions there have been odd combinations e.g. omelette with gravy poured on it and scampi presented the same way. The meals seem to be improving. The management team has informed us that meal provision has been reviewed, further work is requires not only on the taste but also on the delivery and times. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 26 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. The systems and arrangements in place at the home do not ensure that people can be confident that their views are listened and responded to. Overall the home is failing to safeguard peoples health and well-being to ensure their health and well-being is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure that is available enabling people to raise concerns where necessary. Relatives and people living in the home were aware of the procedure to make a complaint. The home’s complaint log contained 18 formal complaints since the previous key inspection in February 2008. The type of issues raised varied and were across all four units within the home. The home has a system in place to record complaints, the investigation and the outcomes. However, it is concerning that there are repeated failings about similar matters suggesting that the home is not learning from the investigations and putting appropriate systems in place to prevent re-occurrences of the same issues. Relatives Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 27 have contacted us on a number of occasions, as they felt the concerns they raised had not been addressed fully and the same matters keep re-occurring. We have received-four complaints from relatives; three were referred to the home for investigation and one was referred to Adults and Communities under the Adult Protection Procedures. There have been a high number of referrals under the Safeguarding Procedures from a variety of statutory agencies. A number of these matters are still unresolved and BUPA is seeking information about what is still outstanding. Staff (53) have recently received training about safeguarding procedures. The management team have been systematically retraining all staff in respect of the safeguarding procedures since September 2008. A number of staff spoken to during the inspection confirmed they had received training in respect of safeguarding, which should provide them with the knowledge of how to respond in the event of an allegation of abuse. A number of staff said the training was lacking in detail and one person stated that the training is in a booklet form and is forgotten almost as quick as I have read it. This raises concerns about the training and culture within the home due to the high number of safeguarding referrals made by external professionals compared to those made by the home. There was no evidence that any staff had completed training in respect of the Mental Capacity Act 2005 so that they were aware of their responsibility in supporting people who lacked mental capacity to make decisions. The training schedule indicated one training session was planned for the future. This is concerning as this legislation has been available for some time and a significant number of people living in the home have some form of cognitive impairment. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 28 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19.20.21.22.23.24.25.26 Quality in this outcome area is Adequate Some improvements are needed to ensure that it is suitable to meet the needs of all people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All four units were visited during the inspection. The four units are linked to the main block by a covered access. The main block contains the kitchen laundry and the administration area. All four units are built to the same design. Bedrooms are all off an “H” shaped set of corridors and are singly occupied with wash hand basins only. The communal area (sitting and dining areas) and Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 29 the office are at one end. There is a fully equipped kitchen attached to the dining area. There is a small sitting room with chairs and sofas for private use by visitors, relatives and staff. The lounges have two televisions, a music system with radio and CD facilities, plus a selection of Videos, DVD’s and CD’s, so there was a choice of entertainment facilities available. Bathrooms and toilets are positioned conveniently around the corridors and have special equipment in them to support people with their mobility. At the last inspection issues were raised with the storage of equipment in bathrooms and the suitability of bathing equipment that impacted on peoples bathing experience. This was not reviewed at this inspection as the management team stated there is a refurbishment plan for the forth-coming year. Bathrooms on the Perrywell unit had keypad locks to doors, and it was found that the water from one hot water outlet over a wash hand basin was too hot to touch when checked by the inspectors. This may be a potential hazard and staff will need to undertake risk assessments for people who use this bathroom to ensure peoples safety in the home. In addition, cleaning items were found stored and accessible to people in a bathroom on Calthorpe unit. These should be stored in a locked cupboard to reduce the risk of accidents and the unit manager actioned it immediately. Bedrooms are personalised and people are able to bring in their own possessions to reflect their tastes and interests. Bedrooms visited were clean and tidy, but furniture in all of the units was beginning to look tired and worn and will need replacement in the near future. At the random visit in October 2008 was observed to have a bolt on the exterior of their bedroom door. The family had requested this to stop other people wandering into the bedroom. This raised questions as to safety of the person in the event of a fire and this decision was made without a multi-agency agreement. This was discussed with the management team and the bolt was removed. BUPA recently arranged for an expert in dementia care to visit the Perrywell Unit. Following this they suggested a number of changes be made to make it a more suitable environment for people living in the home. We were advised that these changes are to be part of their action plan for refurbishing the home. On the Perrywell unit memory boxes were observed outside bedrooms. This is an aid to orientation and personalise the surroundings of people who live there. Items such as fishing rods and models of cars etc are located around the various corridors on the Perrywell unit to aid memory and orientation. One of these items was not fixed to the wall which was of concern as a people living at the home have exhibited challenging behaviour and recently a television was thrown. We were informed post inspection that painters and decorators had visited the Perry well unit and decoration work had started. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 30 A pungent odour was evident in the lounge and dining area on the Perrywell Unit, and it became particularly overpowering during the afternoon period when the sun was shining through the windows. It is concerning that these issues had been identified during the inspections since 2006. This matter has been subject of concern for a long period of time and the cause of upset and disaffection by visiting professionals and more importantly people living at the home and their relatives. The BUPA management team have sought external advice on how to clean and eliminate the odour from the carpet. The carpets on the corridors and at the threshold of the bedrooms were worn down to the backing and underlay. The inspectors were informed on the second day of the inspection visit that an order for new carpet had been placed that day and this should laid in the next few months. We were advised at the feedback meeting that the carpets on Perrywell are to be replaced before the end of December 2008. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 31 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. People living in the home are not always supported by suitably trained staff in the right numbers to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the random visit in October 2008 it was identified that the home continued to work at staffing levels, which were considered the absolute minimum based on a staffing formula from the Health Authority some years ago. What is of further concern is that as the number of people living at the home had decreased the number of staff had decreased. This decrease in staffing numbers has taken place at a time when serious concerns have been identified in meeting the needs of people living in the home. The number of staff varied from 2 trained nurses and four or five carers depending on the number of residents on each unit during the day. Observations during this inspection demonstrated that care practice was task orientated and that these staffing levels were inadequate to meet peoples needs e.g. people receiving breakfast late, problems with meeting peoples nutritional needs, the use of chairs to restrict peoples movement etc. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 32 Comments from visitors and people living in the home included, Staff very good; Staff are very busy during the day, so may have to wait a while; They care, would be much better if they had more carers as I think it is far too for the few that are, as they are always short on the carers; I wish they had more time, staff to talk to her more and see to her less important needs; Staff are kind and caring; When the phone rings it is rarely answered, so I know there is no point in phoning. Some residents keep calling nurse and have to wait for a response; They are a lot busier than they were a year ago. The management team were made aware of this during the visit about staffing arrangements and the ability to answer call bells. The system for summoning assistance needs to be reviewed to ensure peoples needs are met in a timely manner and the management team were made aware of this. We were informed by BUPA on 5 December 2008 that one extra carer would be available on Perrywell and Brooklyn unit. They would also be reviewing the profile of staff across all units to ensure staffing levels are appropriate to meet the dependency needs of people on each unit and it would be completed by the end of January 2009. A sample of staff recruitment files were inspected and it was found that information was missing in respect of the recruitment process. In addition, it was identified that one member of staff had been suspended without prejudice but no record of this could be found in their file eventually evidence to support this was located with the assistance of a member of the management team. The management team should review the administration processes within the home to enable easy and accurate retrieval of information. There was an induction-training programme available and this meets the standards of the Social Skills Council. Carers undertake a three day induction programme where they are supernumerary for one day when they commence employment and gradually work through a training booklet over a 12-week period. Staff confirmed this training took place. The training matrix demonstrated the majority of staff had received manual handling training in the past. However, only forty out of one hundred and sixty had received the training since September 2008 despite concerns raised at previous inspections and subsequent events within the home. On the Perrywell unit eight trained members of staff and ten care staff had undertaken dementia training. The majority of staff who have not received this training are based on night duty. This is concerning as dementia care is not only related to day time hours and a number of safeguarding referrals have been in relation to night time incidents. Staff on Perrywell informed us they were unsure of the procedures for managing challenging/violent behaviour. Staff confirmed that they did have Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 33 dementia training that included a challenging behaviour element, but felt it gave them no practical solutions to use in such circumstances. One member of staff told us another member of staff had been backed into a corner by a verbally hostile and physically threatening person who was living at the home. Staff said they had no idea how to help or what to do to keep each other safe as well as people living in the home. The majority of staff had completed some safeguarding training early in 2008. This has been repeated and fifty-three members of staff out of one hundred and sixty have received further Safeguarding training since September 2008. This will need to continue as the majority of safeguarding referrals came from external agencies. Whilst it could be seen that BUPA were providing training in a number of core areas it also became clear the training was failing to rises awareness, improve practice and ensure people were adequately and safety care for. There was evidence of some staff meetings occurring and inspectors saw minutes. In one of the meetings there was a comment, Training not good, we just read from books. Also a member of staff stated, It is forgotten almost as quick as I have read it. This indicates that the way training is delivered is not always appropriate to the learning needs of staff. This will need to be reviewed and action taken to ensure the training is in a format that influences staff practice. The home was asked to supply this information to us post inspection, as it was not gathered at the time of the visit. The home stated that the home had 41 of staff trained to NVQ 2 or equivalent in care. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 34 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,38 Quality in this outcome area is poor. The Home is not being run in order to meet the best interests of people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been no Registered Manager in the home since June 2008. A care manager from another BUPA home took control of the day to day running of the home since June 2008, but we have not received an application for her to be registered as the manager of the home. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 35 There is a clear trail of a downward decline in the homes overall performance since last year. The home failed to deliver on these improvements and is now rated as poor and we are considering ongoing enforcement action. In these 10 to 12 weeks there has been no measurable improvement. Following this inspection a Director of BUPA has informed us that the management arrangements for the home have been reviewed again. The home has developed a very poor style of management. It appears to have been reactive rather than proactive without any leadership or mentoring to improve practice and overall care delivery. For example when the immediate requirement about the use of kirton chairs was made the manager phoned the nurse in charge of the Perrywell unit and conveyed the information. The nurse in charge of the unit went out and conveyed this message to staff that kirton chairs could no longer be used as they were restraining people. This left staff on the floor confused, angry and disaffected. Staff spoken to generally felt they were not supported by the managers or the organisation. Comments included, Not enough carers; too many nurses who do nothing; Why do we keep getting the blame for poor care when the nurses are supposed to help us; The pay is poor, I stay because I cant get another job; It would be nice to be told why things have to change instead of just doing it; Nurses sticking to medication and do not help us; Why cant all the nurses come on the floor; Permanent staff are going off sick; Don’t feel supported; Don’t feel appreciated; When we are left we two carers they keep telling us the numbers are going to be cut down. This suggests a low staff morale and poor teamwork, which ultimately affects the standard of care delivered to people living in the home. There have been residents and relatives meetings recently and this is a new development. This has lead to four relatives contacting us for further information. There are systems in place to monitor quality aspects in the home. The quality and compliance team, which is separate to the BUPA operational branch of the organisation, has been working in the home since September 2008 to address the concerns raised by a range of organisations including us. They have forwarded regular improvement plans to us and Adults and Communities demonstrating the work taking place. Following feedback from this inspection the quality and compliance team have revisited the improvements plan and have decided to concentrate on a number of key areas. It is concerning that despite all this input outcomes for people living in the home have not improved. Finances for people living in the home were discussed with one of the homes administrators. Money is held in a bank account, which has sub accounts for each individual persons money. The administrator stated that no cash is held on site, but if people want cash this could be obtained for them. The Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 36 administrator stated that the provider audits the accounts and the home is never aware when these audits will take place. A sample of records in relation to servicing and checking of equipment were inspected to determine health and safety systems in the home. In the main these were found to be satisfactory with the exception of the current hard wiring electrical certificate to demonstrate this met the required safety standards. BUPA management team were unable to locate this at the time and were given the opportunity to forward it to us. This was forwarded to us post inspection and was found to be satisfactory. It was first identified at the October 2008 random inspection that there was no individual personal evacuation plan in place for people living at the home. A requirement was made in relation to this and this had not been addressed at this inspection. This places the safety and welfare of people at risk and noncompliance will be reviewed with the enforcement team. The Regional Registration team received an application prior to this key inspection for an increase of eight beds to the Perry well unit. However, due to the serious concerns along with developing enforcement concerns at this moment in time about the ability of the home to care for the people already living there this application has now been withdrawn by BUPA. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 37 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 3 2 2 3 3 2 1 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 X 3 X X 3 Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 38 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12(1) Requirement Timescale for action 09/01/09 2 OP7 12(1) 3 OP7 12(1) 13(4) Unexplained injuries must be investigated and action taken to promote the safety and wellbeing of people living in the home which may include a safeguarding referral. Arrangements must be in place 09/01/09 so that people who use the service are supported to receive adequate nutrition. This will make sure that their nutritional needs are met. Care plans must be based on a 26/11/08 though assessment of needs and show how care is to be delivered. Care plans must be accessible to the staff delivering the care and be a reflection of the care being given. Care plans must be reviewed and amended at the point where a person’s needs change or routinely and staff must be aware of these changes. Not Met. Timescale 29/09/08 4 OP9 18(1)(3) All nursing staff must be trained to understand the clinical DS0000024879.V373246.R01.S.doc 25/11/08 Perry Locks Nursing Home Version 5.2 Page 39 reasons a medicine is administered together with their side effects to ensure that they are able to fully met the clinical needs of the service user. Not met. Timescale 29/09/08, 06/10/08 5 OP9 13(2) The medicine chart must record the current drug regime as prescribed by the clinician. It must be referred to before the preparation of the service users medicines and be signed directly after the transaction and accurately record what has occurred. The right medicine must be administered to the right service user at the right time and at the right dose as prescribed and records must reflect practice Not met. Timescale 29/09/08, 06/10/08 The quantity of any balances carried over from previous cycles must be recorded to enable audits to take place to demonstrate the medicines are administered as prescribed Not met. Timescale 29/09/08, 06/10/08 All medicines that are administered must be stored correctly in accordance with their product licences to ensure that their stability is not compromised. Not met. Timescale 29/09/08, 06/10/08 8 OP9 13(2) A quality assurance system must 25/11/08 DS0000024879.V373246.R01.S.doc Version 5.2 Page 40 25/11/08 6 OP9 13(2) 25/11/08 7 OP9 13(2) 25/11/08 Perry Locks Nursing Home be installed to assess staff competence in their handling of medicines. Appropriate action must be taken when these indicate that medicines are not administered as prescribe and records do not reflect practice, to ensure that all medicines are administered as prescribed and this can be demonstrated. Not met. Timescale 29/09/08, 06/10/08 9 OP9 13(2) At least four hours must elapse between medication rounds to reduce the risk of potential overdose. Not met. Timescale 26/10/08 10 OP9 17(1)(a) The home must keep a record of all the medicines kept in the home and the date on which they were administered to the service user. It must be available for inspection. This is to ensure that all details of the medicines administered to the service user, can be inspected to demonstrate they have been administered as prescribed. 11 OP11 OP9 12(1) Systems must be in place for appropriate pain control and documentation available to demonstrate that peoples receive appropriate pain relief to ensure their needs are met. Not met. Timescale 02/10/08 All staff must receive end of life care training that is appropriate to their position to ensure DS0000024879.V373246.R01.S.doc 26/11/08 14/12/08 26/11/08 12 OP11 12(1) 26/11/08 Perry Locks Nursing Home Version 5.2 Page 41 13 OP18 13(6)37 peoples and relative needs are meet in an appropriate manner. Not met. Timescale 30/10/08 All incidents in relation to adult protection must be reported to the appropriate agencies in a timely manner and the home must have an retrievable audit trail to demonstrate this has occurred to protect and promote well being of peoples. Not Met. Timescale 02/10/08 26/11/08 14 OP18 13(6) The home must ensure that staff are trained and knowledgeable about the safeguarding procedures to ensure all peoples are protected. Not Met. Timescale 30/04/08 26/11/08 15 OP18 12(1) Training must be provided for all staff that work with people who are assessed as having difficult to manage behaviour. This will make sure that their needs are met in a safe way that respects their dignity. All parts of the Care home must be kept clean so that persons living there do not experience unpleasant odours. Made at October 08 visit 09/01/09 16 OP21 23(2)(d) 30/11/08 17 OP22 13(4) Manual handling equipment must be available to ensure people have the type appropriate to their assessed needs and is available in sufficient quantity so it is accessible to staff and in working order. This will ensure people are transferred safety. DS0000024879.V373246.R01.S.doc 09/01/09 Perry Locks Nursing Home Version 5.2 Page 42 18 OP25 12(1) 19 OP27 18(1)(a) 20 OP38 13(5) The water temperature at outlets accessible to people who use the service must be assessed for the risk they present to the people who use the service and action taken to minimise any identified risk. This will make sure that they are safe from the risk of scolding. The home’s Staffing levels must be reviewed so that people living in the home receive care in an appropriate and timely manner that meets their needs. Staff must receive training in manual handling to ensure the safe and well being is promoted and protected. Not Met Timescale 2/10/08 09/01/09 30/11/08 26/11/08 21 OP38 23(3)(c) Arrangements for the evaluation in the event of a fire must be reviewed to ensure that all persons and staff in the care home are not subjected to any unnecessary risk. Not Met Timescale 30/10/08 Persons living in the home should not be have their rights restricted or be placed at unnecessary risk unless this has first been discussed in line with the Mental Capacity Act to include social services the family and the persons GP. Via a multi disciplinary. Not Met Timescale 30/10/08 Staff must attend fire drills twice a year to ensure the safety of everyone in the home. 26/11/08 22 OP38 13(4)(c) 26/11/08 23 OP38 13(4) 09/01/09 Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 43 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The registered person must ensure the statement of purpose and Service User Guide includes all relevant information in a format accessible to people, so that they can make an informed choice. (Not implemented on 26.11.08) 2 OP3 3 OP7 4 5 6 OP8 OP9 OP9 The home should ensure that it collects pre-admission information in a comprehensive and individualised manner so that it provides a person centred approach to meeting that persons needs once living in the home. Trained staff working at the home should re-familiarise themselves with the NMC Record Keeping document to promote and protect the health and well being of people living in the home. (Not fully Implemented on 26/11/08) Call bell response times need to improve to ensure that people do not wait excessive amounts of time for their needs to be met. The controlled drug cabinet should be reserved for the storage of controlled drugs only. Trained staff working at the home should re-familiarise themselves with the NMC Standards of Medicine Management to promote and protect the health and well being of people living in the home. (Not fully Implemented on 26/11/08) The home must consider the arrangements for ensuring the privacy and dignity of all peoples in relation to appropriateness of dress, movement around the home and interactions. (Not implemented on 26.11.08) 7 OP10 8 OP10 Movement of peoples in bucket/curtain and kirton chairs must be reviewed and action taken to ensure people and staff safety plus the dignity and well being of peoples being transported. (Not implemented on 26.11.08) 9 OP12 Activities must be reviewed and based on individual needs. Following this review an action plan should be drawn up and findings implemented. DS0000024879.V373246.R01.S.doc Version 5.2 Page 44 Perry Locks Nursing Home 10 OP14 (Not implemented on 26.11.08) It is recommended that the home obtain a copy of the Dept of Health guidance Mental Capacity Act 2005 core training set published July 2007 and staff are provided with training, so that staff are aware of their responsibility and peoples rights are protected. (Not implemented on 26.11.08) 11 OP15 The home must review the mealtime experience for peoples in the home, to ensure that the quality meets the preference of peoples and is served at the appropriate temperature and time. (Not implemented on 26.11.08) 12 13 14 OP16 OP18 OP20 Management of complaints must be reviewed so that they are dealt with appropriately and sensitively and do not reoccur. Staff at the home need to follow their own policies and procedures in relation to restraint to ensure no ones rights are restricted. It is recommended that the home contact RNIB for guidance on the appropriate lighting conditions for peoples with sight impairments. (Not implemented on 26.11.08) 15 OP21 The refurbishment programme must review the bathing facilities and ensure that these are suitable to meet people’s needs. (Not implemented on 26.11.08) 16 OP21 17 OP29 18 OP29 19 OP30 The physical environment should be reviewed for people living on the Perry Well unit and plans put in place to ensure that it meets their needs. (Not fully implemented on 26.11.08) Trained staff working at the home should re-familiarise themselves with the NMC The Code Standards of conduct, performance and ethics for nurses and midwives to promote and protect the health and well being of people living in the home. Carried forward from Sept 08 visit Staff files should be organised to ensure all information is available and does not hinder the smooth running of the home. Shortfalls identified in training needs such as dementia, challenging behaviour, Mental Capacity, tissue viability, and safeguarding must be addressed in the appropriate learning style so that this training embeds. This will ensure that DS0000024879.V373246.R01.S.doc Version 5.2 Page 45 Perry Locks Nursing Home knowledge and practice mirror and meet the needs of residents. 20 21 OP32 OP32 Communication systems at all levels must be reviewed to ensure people who live at the home have all their needs met. The management team must review the systems of support for staff to ensure the workforce can perform appropriately. The management team needs to capture the commitment of those staff who show an excellent level of commitment by ensuring these members of staff are supported to have the skills and competencies to deliver care that meets peoples needs. (Not Implemented on 26/11/08) 22 OP33 Issues identified in the quality assurance system must be swiftly addressed and monitored on a regular basis to ensure and developments have a positive outcome for peoples. (Not implemented on 26.11.08) 24 OP38 25 OP38 Staff must attend fire drills twice a year to ensure the safety of everyone in the home. BUPA training package in relation to bedrails should be shown to all staff working at the home. Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 46 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Perry Locks Nursing Home DS0000024879.V373246.R01.S.doc Version 5.2 Page 47 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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